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Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA)

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA). 34th Congresso Brasileiro de Pneumologia e Tisiologia Brasilia, Brazil, 2008 Henri Colt MD University of California, Irvine hcolt@uci.edu. Objectives. Role of nodal staging in nonsmall cell lung cancer

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Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA)

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  1. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration(EBUS-TBNA) 34th Congresso Brasileiro de Pneumologia e Tisiologia Brasilia, Brazil, 2008 Henri Colt MD University of California, Irvine hcolt@uci.edu

  2. Objectives • Role of nodal staging in nonsmall cell lung cancer • Invasive and noninvasive modalities • EBUS principles, technique and instrumentation • EBUS and CT, EBUS and PET, EBUS and mediastinoscopy • EBUS: new developments

  3. Background Non-small cell lung cancer (NSCLC) the leading cause of death from malignant diseases worldwide despite advances in surgical and multimodality treatment. Accurate staging of the disease is mandatory not only to determine the prognosis but also to decide the most suitable treatment plan. The most significant treatment decision is identifying patients who can benefit from surgical resection.

  4. Background The presence of lymph node metastasis remains one of the most adverse factors for prognosis in NSCLC The presence of mediastinal lymph node involvement indicates the presence of stage IIIA or IIIB, which suggests either inoperability and/or the need for treatment by chemotherapy and/or radiotherapy

  5. Survival based on nodal invasion

  6. Staging N factor Non-invasive staging (Imaging) CT, MRI, PET, PET-CT, EBUS, EUS Invasive staging (Sampling) Surgical open biopsy (Med, VATS) Needle Biopsy (TBNA, TTNA, EUS-FNA)

  7. Staging N factor - Needle biopsy Chest. 2003; 123: 157-66 Radiol. Clin. North Am. 2000; 38: 525-34 Cardiovasc. Intervent. Radiol. 1991; 14: 17-23 Clin. Chest Med. 1993; 14: 99-110 Chest. 2001; 120: 1037-8 Chest. 2000; 118: 936-9 Transthoracic Needle Aspiration Performed by interventional radiologists CT or fluoroscopic guidance High sensitivity in enlarged nodes 91% Low false negative rate 20-50% High incidence of pneumothorax 5-60% Implantation rare but possible

  8. Staging N factor - Needle biopsy Ann. Surg. 2003; 238: 180-8 Chest. 1990; 98: 586-93 Endoscopy. 1994; 26: 784-7 Ann. Thorac. Surg. 1996; 61: 1441-5 Chest. 2000; 117: 339-45 Lung Cancer. 2003; 41: 259-67 Am. J. Respir. Crit. Care Med. 2003; 168: 1293-7 EUS-FNA Only modality for #8, #9 LN Limited to left paratracheal Sensitivity 81-97% Specificity 83-100% Major drawback high false negative rate

  9. TBNA – Different Methods Conventional TBNA CT guided TBNA Electromagnetic Navigation guided TBNA Ultrasound guided TBNA 1) Radial Probe guided 2) Convex Probe guided (real time) EBUS-TBNA

  10. Conventional TBNA Chest. 1983; 84: 571-6 Chest. 1989; 96: 1228-32 Am. Rev. Respir. Dis. 1986; 134: 146-8 Chest. 2003; 123: 157-66 Chest. 2005; 128: 869-75 Sensitivity 14-91% (operator dependent) Failure to place needle directly into LN Depends on LN size and station High false negative rate

  11. CT guided TBNA Chest. 1998; 114: 36-9 Chest. 2000; 118: 1630-8 Chest. 2001; 119: 329-32 Radiology. 2000; 216: 764-7 High yield 83-88% Requires use of CT suite (costly) Radiation exposure (both Pt and operator) Confirmation of needle outside of LN (42.1%)

  12. Navigational TBNA V

  13. Navigational TBNA Return on investment ??

  14. EBUS-TBNA Fairly new diagnostic procedure (1999) -2002: convex probe (real-time guidance) Originally developed for lymph node staging Other diagnostic uses Intrapulmonary tumors Unknown hilar or mediastinal LAD Mediastinal tumors

  15. Medium A B C D Ultrasound Transducer 1 2 2 2 3 4 4 4 5 Ultrasound Image Tissue density Angle of probe with target tissue Acoustic impedence

  16. Angle of examination and angle of insertion will be important

  17. Endobronchial Ultrasound: principles piezoelectric crystal standard frequency for EBUS is 20 MHz (radial) 7.5 MHz (convex) 6.9 mm

  18. The Processor

  19. Physics Definition: wave length US > 20 KHz Diagnostic 2-20 Mhz Chest US: 3-5 MHz EBUS: 20 MHz 7.5 MHz penetration resolution

  20. EBUS-TBNA Linear curved transducer Images obtained by attaching a balloon and inflating with normal saline Image is processed Lesions can be measured Images can be frozen Doppler mode 22-gauge needle Internal sheath

  21. EBUS-TBNA

  22. Use of Doppler demonstrates blood flow

  23. Needle insertion

  24. Example EBUS-TBNA level R10 node VIDEO

  25. EBUS-TBNA All mediastinal lymph nodes accessible except: Subaortic (5 and 6) Paraesophageal (8 and 9) Gen Thorac Cardiovasc Surg (2008) 56: 268-276

  26. Results of EBUS • METHODS: This was a retrospective analysis of 152 consecutive patients who underwent EBUS-TBNA with undiagnosed intrathoracic adenopathy or cancer staging as the primary indications. • The procedures occurred between January 2005 and June 2006 at a single academic medical center. Of the 152 patients. • 117 were included in the final statistical analysis after excluding those with benign disease diagnosed by • EBUS-TBNA. Rapid on-site cytopathologic examination was used in all cases. Vincent BD, Ann Thorac Surg. 2008

  27. Real-time endobronchial ultrasound-guided transbronchial lymph node aspiration. • RESULTS: Malignancy was identified in 113 patients, of which 67 (59.3%) had non-small cell lung carcinoma, and 20 (17.7%) underwent surgical resection. • Four patients had benign diagnoses at surgical pathology. Only 1 surgical patient was found to have nodal metastasis at a lymph node station previously biopsied by EBUS-TBNA (negative predictive value, 97%). • Compared with radiologic staging, EBUS-TBNA down-staged 18 of 113 (15.9%) and up-staged 11 (9.7%). Sensitivity was 98.7%, with 100% specificity. No major complications were associated with the procedure. • CONCLUSIONS: EBUS-TBNA is useful in accessing mediastinal and hilar lymph nodes for the diagnosis and staging of non-small cell lung cancer and other disorders of the mediastinum. Thoracic surgeons and pulmonologists are well positioned to use this tool in everyday practice. Vincent BD, Ann Thorac Surg. 2008

  28. Minimally invasive endoscopic staging of suspected lung cancer • Comparison of the diagnostic accuracy of 3 methods of minimally invasive endoscopic staging (and their combinations): • traditional transbronchial needle aspiration (TBNA) • endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) • transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) Wallace MB, et al, JAMA. 2008

  29. Minimally invasive endoscopic staging of suspected lung cancer • 138 patients: • 42 (30%) had malignant lymph nodes. • EBUS-FNA: more sensitive than TBNA, detecting 29 (69%) vs 15 (36%) malignant lymph nodes (P = .003). • EUS plus EBUS: higher estimated sensitivity (93% [39/42]; 95% confidence interval, 81%-99%) and negative predictive value (97% [96/99]; 95% confidence interval, 91%-99%) compared with either method alone. Wallace MB, et al, JAMA. 2008

  30. Minimally invasive endoscopic staging of suspected lung cancer • EUS plus EBUS • higher sensitivity and higher negative predictive value for detecting lymph nodes in any mediastinal location and for patients without lymph node enlargement on chest computed tomography • EBUS-FNA • higher sensitivity than TBNA Wallace MB, et al, JAMA. 2008

  31. Conclusion • EUS plus EBUS • may allow near-complete minimally invasive mediastinal staging in patients with suspected lung cancer • may be an alternative approach for mediastinal staging in patients with suspected lung cancer

  32. 1<2<3 Conventional TBNA EBUS OR EUS guided TBNA EBUS AND EUS guided TBNA Multidisciplinary lung cancer groups evaluates patients based on disease process rather than on medical/surgery specialty ???

  33. Lung CA Staging: overview ACCP Invasive mediastinal staging 2002: Revised 4 years later Highlights Extensive mediastinal infiltration Invasive staging not needed Discrete mediastinal lymph node enlargement Staging by CT or PET not sufficient Invasive staging required Normal sized lymph nodes -> mediastinoscopy Clinical N1 (Stage II) or central tumor Mediastinoscopy EBUS is an accepted alternative Chest 2007; 132; 202-220

  34. Lung CA Staging: overview ACCP Invasive mediastinal staging PET positive LAD in Stage I Invasive staging is required EBUS alternative Overall EBUS-TBNA is reasonable as long as nondiagnostic results are followed by Mediastinoscopy Mediastinoscopy is still the Gold Standard Still no study that directly compares mediastinoscopy to EBUS-TBNA Chest 2007; 132; 202-220

  35. Comparisons: Different modalities

  36. Endobronchial Ultrasound: clinical applications guidance of mediastinal lymph node biopsies (J Bronchol 2006;13:84–91) Herth FJ et al. Ultrasound-guided transbronchial needle aspiration: an experience in 242 patients. Chest 2003;123:604 –7.

  37. Review of the literature: EBUS and… • Conventional TBNA • EUS and TBNA • Conventional mediastinoscopy • PET and CT • PET • Guiding bronchoscopic therapies • Lymph node size • Metastatic lung tumors • Normal mediastinum CT negative, and PET negative • CT, PET and surgical staging gold standard

  38. 1. EBUS and TBNA CHEST 2004; 125:322–325

  39. 2. EBUS and EUS Am J Respir Crit Care Med Vol 171. pp 1164–1167, 2005

  40. EBUS, TBNA, and EUS

  41. 3. EBUS vs. mediastinoscopy EBUS-TBNA 502 patients 572 Lymph nodes Nodes (2l, 2r, 3, 4r, 4l, 7, 10r, 10l, 11r, and 11l) Mean diameter 1.6 (range.8-4.3) 535 resulted in diagnosis (94%) Mediastinoscopy to confirm biopsy Sensitivity 94% Specificity 100% PPV 100% Recorded no complications Herth et. al. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax 2006 61; 795-798

  42. 4. EBUS vs CT, TBNA, and PET Comparison of EBUS-TBNA, PET, and CT CT scan: lymph nodes positive if > 1cm PET scan: lymph nodes positive if uptake >2.5 EBUS-TBNA: lymph nodes >5mm Results 280 patients evaluated 102 patients met criteria Underwent CT and PET EBUS-TBNA 147 mediastinal and 53 hilar nodes Surgical histology was then used for comparison Yasufuku et al. Comparison of Endobronchial Ultrasound, PET, and CT for Lymph Node Staging of Lung Cancer. Chest 2006; 130:710-718

  43. EBUS and Staging Yasufuku et al. Comparison of Endobronchial Ultrasound, PET, and CT for Lymph Node Staging of Lung Cancer. Chest 2006; 130:710-718

  44. Size of PET negative nodes impacts probability of malignancyMediastinal lymph nodes and relation with metastatic involvement: a MetanalysisLangen et al, Eur J Cardiothorac Surg 2006;29:26-29 • Probability for malignancy in lymph nodes measuring 10-15 mm in the short axis is 29%,and about 60% if nodes are larger. • If nodes 10-15 mm and PET Negative, probability for malignancy is 5%. • Refrain from mediastinoscopy • If nodes > 16 mm and PET Negative, probability for malignancy is 21%. • Proceed with mediastinoscopy

  45. 5a. EBUS and PET positive nodes Performance of TBNA using linear EBUS (real-time EBUS-TBNA) under local anaesthesia and the value of PET for prediction of pathological results were assessed Number of eluded surgical procedures was evaluated Bauwens O, et al, Lung Cancer 2008

  46. EBUS and PET positive nodes in lung cancer • 106 Patients with suspected/proven lung cancers and FDG-PET positive mediastinal adenopathy • Av. # of TBNA samples/patient: 4.9+/-1.1 • Prevalence of lymph node metastasis- 58%. • Results of EBUS-TBNA staging of mediastinal hot spots: • 95% sensitivity, 97% accuracy, 91% negative predictive value. Bauwens O, et al, Lung Cancer 2008

  47. Conclusion • Surgical procedures • eluded in 56% of the patients • Real-time EBUS-TBNA • should be preferred over mediastinoscopy as first step procedure in staging of PET mediastinal hot spots in lung cancer patients Bauwens O, et al, Lung Cancer 2008

  48. 5b. EBUS and PET positive mediastinal lymph nodes diagnostic/staging yield of TBNA following EBUS localization was assessed number of avoided surgical procedures was evaluated 33 patients referred for staging and/or diagnosis of mediastinal FDG-PET positive lesions Plat G, et al, Eur Respir J. 2006

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